Provider Demographics
NPI:1699104927
Name:KANCHERLA, NISHA MANIAR (DMD)
Entity type:Individual
Prefix:DR
First Name:NISHA
Middle Name:MANIAR
Last Name:KANCHERLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:NISHA
Other - Middle Name:BHARAT
Other - Last Name:MANIAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3644 VIA NUOVA LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 KILLIAN HILL RD NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3809
Practice Address - Country:US
Practice Address - Phone:770-921-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0397921223P0300X
GADN0159701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty